Basic Information
Provider Information | |||||||||
NPI: | 1073600706 | ||||||||
EntityType: | 2 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: | THE CENTER FOR ORAL AND MAXILLOFACIAL SURGERY PROFESSIONAL ASSOCIATION | ||||||||
LastName: |   | ||||||||
FirstName: |   | ||||||||
MiddleName: |   | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: |   | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | 16 AIRPORT ROAD | ||||||||
Address2: |   | ||||||||
City: | WEST LEBANON | ||||||||
State: | NH | ||||||||
PostalCode: | 037841681 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 6032987557 | ||||||||
FaxNumber: | 8888573155 | ||||||||
Practice Location | |||||||||
Address1: | 16 AIRPORT ROAD | ||||||||
Address2: |   | ||||||||
City: | WEST LEBANON | ||||||||
State: | NH | ||||||||
PostalCode: | 037661681 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 6032987557 | ||||||||
FaxNumber: | 8888573155 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 10/06/2006 | ||||||||
LastUpdateDate: | 07/21/2022 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: |   | ||||||||
AuthorizedOfficialLastName: | COHEN | ||||||||
AuthorizedOfficialFirstName: | CRAIG | ||||||||
AuthorizedOfficialMiddleName: | H | ||||||||
AuthorizedOfficialTitleorPosition: | PRESIDENT | ||||||||
AuthorizedOfficialTelephone: | 6032987557 | ||||||||
IsSoleProprietor: |   | ||||||||
IsOrganizationSubpart: | N | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: | D.M.D. | ||||||||
NPICertificationDate: |   |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 1223S0112X |   | NH | Y | 193200000X MULTI-SPECIALTY GROUP | Dental Providers | Dentist | Oral and Maxillofacial Surgery |
No ID Information.